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PS-044 Streamlining medicines error reporting functionality within a clinical pharmacy intervention program
  1. I Khudair,
  2. A Zena,
  3. R Al Anany
  1. Hamad General Hospital, Pharmacy Department, Doha, Qatar


Background Medication errors (MEs) are defined as any errors occurring in the process of using a medicine, regardless of whether an injury occurred or the potential for injury was present (near miss). Traditional error reporting systems have limited success due to the time involved in reporting, complicated processes, inadequately friendly user interfaces and the use of paper-based reporting. We explored the effect of a new integrated reporting process by making the error reporting link within a clinical pharmacist intervention documentation program. The result could improve reporting rates and details for accurate internal quality review and improve medicines use systems.

Purpose To examine medication error reporting rates, types of error and staff involvement in reporting through the new electronic system, which is integrated into a clinical pharmacy intervention program and to compare the outcome with the previous paper-based system.

Materials and methods Interventional study comparing paper-based reporting at baseline (6 months preceding the intervention, June–November 2012) with reporting after the electronic system was introduced (December 2012–May 2013). Error reporting functionality was made by asking the key question ‘Did this intervention detect/correct an error?’. If yes, the error was categorised according to National Coordinating Council for Medication Error Reporting and Prevention index (response range from A to I).

Results Baseline ME reporting created 12 reports (9 category D and 3 E) initiated by 25% of the clinical pharmacy staff. 6 months after introducing the electronic link, the number had risen to 377 reports initiated by 78% of clinical pharmacy staff (reports were 118 near misses (category A&B), 196 C, 42 D, 10 E, 10 F and 1 H).

Conclusions By using a streamlined interface design, we were successfully able to improve reporting rates, details of MEs and staff involvement in this setting. The resultant system was encouraging and reflects error reporting more accurately, which will allow us to understand the factors contributing to these errors and to establish prevention strategies.

No conflict of interest.

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